Femoral Nonunion:

Risk Factors and

Treatment Options
Joseph R. Lynch, MD
Lisa A. Taitsman, MD, MPH
David P. Barei, MD
Sean E. Nork, MD

Dr. Lynch is Fellow and Acting Instructor,

Department of Orthopaedics and Sports
Medicine, University of Washington
School of Medicine, Seattle, WA. Dr.
Taitsman is Assistant Professor,
Department of Orthopaedics and Sports
Medicine, University of Washington
School of Medicine. Dr. Barei is
Associate Professor, Department of
Orthopaedics and Sports Medicine,
University of Washington School of
Medicine. Dr. Nork is Associate
Professor, Department of Orthopaedics
and Sports Medicine, University of
Washington School of Medicine.
None of the following authors or a
member of their immediate families has
received anything of value from or owns
stock in a commercial company or
institution related directly or indirectly to
the subject of this article: Dr. Lynch, Dr.
Taitsman, Dr. Barei, and Dr. Nork.
Reprint requests: Dr. Lynch, Department
of Orthopaedics and Sports Medicine,
University of Washington Medical
Center, Box 356500, 1959 NE Pacific
Street, Seattle, WA 98195.
J Am Acad Orthop Surg 2008;16:
88-97
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.

88

Abstract
Despite advances in surgical technique, fracture fixation
alternatives, and adjuncts to healing, femoral nonunion continues
to be a significant clinical problem. Femoral fractures may fail to
unite because of the severity of the injury, damage to the
surrounding soft tissues, inadequate initial fixation, and
demographic characteristics of the patient, including nicotine use,
advanced age, and medical comorbidities. Femoral nonunion is a
functional and economical challenge for the patient, as well as a
treatment dilemma for the surgeon. Surgeons should understand
the various treatment alternatives and their role in achieving the
goals of deformity correction, infection management, and
optimization of muscle strength and rehabilitation. Used
appropriately, nail dynamization, exchange nailing, and plate
osteosynthesis can help minimize pain and disability by promoting
osseous union. A review of the potential risk factors and treatment
alternatives should provide insight into the etiology and required
treatment of femoral nonunion.

anagement of femoral diaphyseal fractures with a medullary device typically results in union
rates ranging between 90% and
100%.1-3 Nevertheless, femoral nonunion does occur. The incidence
may be higher than previously reported, given the greater likelihood
of survival of the polytraumatized
patient and improved limb salvage
techniques. The patient with femoral nonunion is faced with significant functional and economic problems, including persistent disability,
gait abnormality, and prolonged
physical and psychological disability. Some of the currently available
treatment techniques are successful
in achieving union in only 50% to
80% of patients,4-6 which is much
lower than indicated by the older lit-

erature.7,8 These relatively poor results have sparked interest in the development of newer implants9 and
biologic agents.10,11 Surgeons must
counsel patients appropriately and
choose the optimal intervention for
the specific characteristics of the patient and nature of the injury.

Definition of Nonunion
The definition of nonunion typically
hinges on three important variables:
the duration of time since the injury,
characteristics of the fracture noted
on serial radiographs, and clinical parameters that the treating surgeon
can identify with a careful history
and thorough physical examination.
Currently, the US Food and Drug Administration (FDA) defines nonunion

Journal of the American Academy of Orthopaedic Surgeons

Joseph R. Lynch, MD, et al

as a fractured bone that has not completely healed within 9 months of

injury and that has not shown progression toward healing over 3 consecutive months on serial radiographs.12 Many authors suggest that
the optimal time for healing is from
4 to 12 months, depending on the
bone in question, the location of the
fracture, the nature of the injury, and
the quality of the soft tissues.5,7,8,13-18
The time it takes a bone to heal is
variable and depends not only on the
aforementioned factors but on the
physiologic capability of the individual patient.
Radiographic criteria that support
the diagnosis of nonunion include
the absence of bone crossing the
fracture site (bridging trabeculae),
sclerotic fracture edges, persistent
fracture lines, and lack of evidence
of progressive change toward union
on serial radiographs. The presence
or absence of callus is less reliable as
an indicator of nonunion; its usefulness is dependent on the index treatment chosen by the surgeon. Callus
formation associated with secondary
bone healing is expected in a diaphyseal femoral fracture treated with a
bridging implant (eg, medullary
nail); thus, the absence of a callus
may be indicative of nonunion.
However, the surgeon should expect
primary bone healing in the fracture
treated with compression plate osteosynthesis in which absolute stability was achieved. In this instance,
the absence of callus would not necessarily be suggestive of nonunion.
Clinically, nonunion may produce persistent pain or motion at the
fracture site, both of which may be
elicited by either direct manipulation during physical examination or
with attempted weight bearing. A
patient may demonstrate an antalgic
gait and require narcotic pain medication and ambulatory assistive devices (eg, cane, crutches). These radiographic and clinical criteria are
important in accurately diagnosing
femoral nonunion.
Volume 16, Number 2, February 2008

Figure 1

A, Lateral radiograph of a viable hypertrophic nonunion of the distal femoral

diaphysis demonstrating abundant fracture callus and an adequate healing
response to the original injury in the setting of inadequate stability. B, Lateral
radiograph of a viable oligotrophic nonunion of the femoral diaphysis demonstrating
little to no fracture callus and an inadequate healing response to the original injury
in the setting of adequate stability. A technetium bone scan would show increased
uptake in this case.

Classification
Femoral nonunions can be classified
according to the criteria described by
Weber and Cech.19 This classification
is based on the principle of osseous
viability, with fractures divided into
viable and nonviable subtypes. A viable nonunion has an intact blood
supply and is capable of mounting
a healing response to injury. Subtypes
within this classification include
hypertrophic nonunion and oligotrophic nonunion. A hypertrophic
nonunion displays exuberant callus
on anteroposterior (AP) and lateral radiographs, demonstrates increased
uptake on radionuclide scans, and
represents inadequate stability in the
setting of an adequate blood supply
and healing response (Figure 1, A). In
contrast, oligotrophic nonunion,
which also has an intact blood supply and demonstrates radiotracer up-

take on radionuclide scans, differs in

that it possesses an inadequate healing response characterized by evidence of little or no callus on AP and
lateral radiographs (Figure 1, B).
A nonviable femoral nonunion is
often called an atrophic or avascular
nonunion. These nonunions demonstrate ischemic or cold radionuclide
scans, indicating a complete lack of
the normal biologic response to injury. Radiographically, atrophic nonunions demonstrate eburnated, osteopenic, and/or sclerotic bone ends.
On occasion, these injuries are radiographically similar, if not indistinguishable, from oligotrophic nonunions (Figure 2). In clinical practice,
viable and nonviable nonunions
usually are identified based on
characteristics observed on serial radiographs. Radionuclide scans are
infrequently used. Nevertheless, dis89

Femoral Nonunion: Risk Factors and Treatment Options

Figure 2

Anteroposterior radiograph of a
nonviable nonunion of the femoral
diaphysis demonstrating an atrophic
and osteopenic fracture with no callus
formation, indicating a lack of an
appropriate healing response to the
original injury. A technetium bone scan
would show decreased uptake in a
case such as this.

tinction is important because this

classification can help guide appropriate treatment.

Diagnosis and
Evaluation
The diagnosis and evaluation of femoral nonunion begins with the patient history and a careful account of
the original injury, including identification of any associated traumatic
open wounds. The patients characterization of pain and fracture site
mobility is important in understanding the nature of the nonunion. Demographic and patient characteristics
that are potential risk factors for nonunion (eg, tobacco use, peripheral
vascular disease, use of nonsteroidal
anti-inflammatory drugs [NSAIDs])
should be recognized. Additionally, it
is important to identify clinical
symptoms of infection, such as mal90

aise, fever, fatigue, night pain, and/or

a history of wound healing problems
(eg, persistent drainage).
The physical examination should
identify deformity, pain at the fracture site, disruption of the soft tissues, warmth, erythema, and drainage. Fracture site stability and pain
on manipulation should be assessed.
An objective evaluation of limb vascularity should document distal
pulses, skin temperature, and hair
distribution. A more formal assessment of vascular integrity may be
warranted for the patient with a history of vascular injury during either
the initial injury or subsequent
treatment. This may be done with
measurement of the ankle-brachial
index or an arterial duplex examination.20
The initial radiographic evaluation includes AP, lateral, and oblique
views (45 internal and external) of
the affected limb. In most patients,
this is sufficient to confirm the radiographic diagnosis of nonunion.
The character of the nonunion (viable versus nonviable), measurement
of the mechanical and anatomic
axes, and preoperative planning can
be determined from these studies.
Examination under fluoroscopy to
assess motion can occasionally be
helpful when the clinical and radiographic diagnoses are inconclusive.
Occasionally, a technetium bone
scan is useful for distinguishing between viable and nonviable nonunions, for diagnosing an occult
nonunion, and for helping choose an
appropriate treatment modality.
This distinction between viable and
nonviable is important when determining the appropriate treatment for
an individual patient. For a patient
with oligotrophic nonunion, the surgeon may opt to attempt a minimally invasive (eg, nail dynamization) or
a noninvasive (eg, ultrasound) technique to achieve union. For a truly
atrophic or nonviable nonunion, osteogenic techniques combined with
an open procedure and skeletal stabilization are recommended.

Computed tomography has been

shown to be more accurate than
plain radiography in the diagnosis of
tibial nonunion.21 Although limited
by metal artifact, it can accurately
assess the integrity of bridging callus, the presence and character of a
pseudarthrosis, and the location and
size of sequestrum in cases associated with infection.
Infection should be a consideration in all cases of femoral nonunion. Thus, preoperative laboratory
analysis should include a complete
blood count with differential, erythrocyte sedimentation rate, and
C-reactive protein level. When the
clinical presentation and laboratory
analysis are suggestive of infection,
radionuclide and indium 111labeled leukocyte scans may be helpful in localizing the extent of disease.22 The benchmark for diagnosis
of infection is tissue culture at the
time of a secondary surgical procedure.23 Antibiotics should be discontinued 7 to 14 days before surgery to
improve the yield of the intraoperative cultures. Intraoperative specimens should be evaluated with a
Gram stain and processed for aerobic, anaerobic, and fungal cultures,
as well as acid-fast stain.

Risk Factors
The four main causes of nonunion
are motion (inadequate fracture stability), avascularity (open fracture,
stripping during surgery), fracture
gap (bone loss, nailing in distraction), and infection. Excessive motion in surgically managed fractures
may result from inadequate initial
fixation and/or implant failure. In
the setting of adequate vascularity,
excessive motion typically results in
hypertrophic nonunion, characterized by an abundance of callus, widening of the fracture site, and failure
of fibrocartilage mineralization.
Avascularity resulting from open
fractures, aggressive reaming, and
excessive surgical stripping may
contribute to the development of a

Journal of the American Academy of Orthopaedic Surgeons

Joseph R. Lynch, MD, et al

nonunion by injuring the periosteal

and endosteal blood supply.24,25 Open
fractures26 have been associated with
femoral nonunion, as has the need
for open reduction during closed
nailing.15 Multivariate analyses indicate that open femur fractures with
significant comminution, indicating
greater soft-tissue stripping, have an
increased risk of nonunion.16 The effect of reaming before nailing is less
clear. Although vascular studies
demonstrate that reaming has a negative impact on endosteal circulation, these studies also demonstrate
a paradoxical rise in periosteal circulation, which is thought to play a
larger role in callus formation.25
Clinical studies analyzing the effects
of reaming for femoral shaft fractures have shown a significantly
greater risk of femoral nonunion
when a nail is inserted without
reaming (7.5%) compared with cases
in which the canal is reamed before
nail insertion (1.7%; P = 0.049).1
The presence of a gap, either because of traumatic bone loss or the
treatment used (nailing in distraction, bony dbridement) also may
contribute to the development of
nonunion.17 Any gap present after
definitive treatment must be bridged
by fracture callus during the healing
process. When bridging cannot occur, further intervention is required
to manage the resulting cortical defect. The magnitude of this defect is
variable and depends on the constellation of injury characteristics as
well as the physiologic capability of
the patient.
Infection can occur as a complication of the injury (eg, open fracture)
or as a complication of treatment.
Infection typically results in the formation of necrotic bone (sequestrum), ingrowth of granulation tissue, osteolysis, and excessive
fracture motion secondary to implant loosening or failure.
Recent studies have demonstrated associations between nonunion
and specific patient variables, such
as tobacco use, NSAIDs, and mediVolume 16, Number 2, February 2008

cal comorbidities. In a review analyzing the Ilizarov technique for reconstruction of the femur and tibia,
McKee et al27 demonstrated significant associations between smoking
and the development of nonunion
(P = 0.031). Retrospective clinical
studies have demonstrated a greater
union rate in nonsmokers (84%)
compared with smokers (58%).28 In a
case-control study of 32 femoral diaphyseal nonunions, Giannoudis et
al14 demonstrated no significant association between smoking and the
development of nonunion. However,
they did find that the use of NSAIDs
increased the relative odds of nonunion dramatically (OR, 10.75; CI,
3.5 to 33.2). In a case-control study
of diaphyseal injuries involving the
femur, tibia, and humerus, Malik et
al15 demonstrated that a higher
American Society of Anesthesiologists (ASA) score (a surrogate for
medical comorbidities; P < 0.001)
was predictive of nonunion.

Treatment of Nonunion
of the Femur
Achieving osseous union without
complications is the ultimate goal of
treatment, but it is not the only goal.
Correction of malalignment, eradication of infection, optimization of
muscle strength, and rehabilitation
are also important. All of these objectives should be considered when
planning a treatment strategy. Beyond a well-planned and executed
surgical procedure, the patients
medical comorbidities and nutritional status should be optimized to
maximize the chances for success.
Additionally, nicotine use and other
medications (eg, NSAIDs, methotrexate) that may negatively affect osteogenesis should be stopped or modified. Treatment options include nail
dynamization, exchange nailing, plate
osteosynthesis, external fixation, and
adjuvant alternatives (eg, electrical
stimulation, bone grafting, bone morphogenetic proteins [BMPs]).

Nail Dynamization
Dynamization refers to the conversion of a statically locked nail to a dynamically locked nail. This is accomplished by the removal of some
combination of the proximal or distal interlocking screws, thereby allowing for controlled axial instability
of the bone-implant construct. In theory, dynamization allows transfer of
weight-bearing forces to the nonunion site, thereby stimulating osteogenesis and fracture union29 (Figure 3).
The stimulus of weight bearing and
intermittent loading in a fracture not
previously subjected to loading may
be sufficient to induce healing.30 This
treatment alternative is relatively
simple to perform and may be effective in axially stable injuries originally managed with statically locked
medullary nails.18
The current literature suggests
that dynamization has a 50% success
rate of achieving union.17,18,31 However, a significant prevalence of complications has been reported. The
most notable is shortening of >2 cm,
which is estimated to occur in 20%
of patients treated with nail dynamization.17,18,31 Fracture characteristics
associated with shortening and treatment failure include long oblique,
spiral, and highly comminuted fractures. Close follow-up is recommended for patients with these fracture characteristics who are treated
with nail dynamization, and careful
consideration should be given to alternative treatment.18 Nail dynamization is best reserved for the axially
stable femoral shaft nonunion. The
use of the dynamic locking hole is
advocated to minimize anticipated
shortening and maintain rotational
stability. Dynamization may be more
effective when performed early (3 to
6 months after injury) rather than
late (ie, with established nonunion).
Exchange Nailing
Exchange nailing refers to the
practice of removing an already
present medullary implant, reaming
the medullary canal to a larger diam91

Femoral Nonunion: Risk Factors and Treatment Options

Figure 3

Anteroposterior (A) and lateral (B) radiographs of femoral diaphyseal nonunion in a 26-year-old man who was treated with a
reamed antegrade statically locked medullary nail. At 7 months following fracture, he presented with an antalgic gait.
Anteroposterior (C) and lateral (D) radiographs demonstrating healing of the femoral diaphyseal nonunion 6 months following
nail dynamization.

eter, and inserting a larger-diameter

nail (Figure 4). This technique stimulates bone union mechanically and
biologically. Sequential reaming enlarges the medullary canal and facilitates insertion of a larger and stiffer
implant. Additionally, exchange
nailing affords greater stability by increasing the length of the isthmic
portion of the medullary canal,
which increases the implantendosteal contact area. The biologic
stimuli that promote union following exchange nailing include the
deposition of autogenous bone graft
at the nonunion site and the stimulation of a periosteal healing response through the process of femoral canal reaming. The actual
amount of reamings that are deposited at the site of the nonunion is unknown but likely is minimal.
Variable rates of fracture consolidation have been reported after exchange nailing for primary treatment
92

of femoral diaphyseal nonunion.4,7,8,13

Kempf et al7 reported a 93% union
rate in their review of 27 patients
with femoral nonunion who were
treated with exchange nailing. Webb
et al8 reported a 97% union rate. In
this series, the fractures that did not
heal following the first exchange
nailing did so after a repeat exchange
nailing procedure. More recent series
demonstrate much lower union rates
following exchange nailing for femoral nonunion.5,13,32 In these series, a
higher prevalence of persistent nonunion among smokers was reported,
but the authors were unable to demonstrate a statistically significant
correlation with other factors, including type of nonunion, fracture location, type of nail, and the use of
statically or dynamically locked
nails.4,5,13 In a retrospective review of
19 femoral nonunions managed with
exchange nailing, Weresh et al5 reported a persistent nonunion rate of

53% at 35 weeks, which challenges

the efficacy of exchange nailing as a
panacea for femoral nonunion. In this
series, 47% of patients required an
additional procedure, including open
autogenous bone grafting, to achieve
osseous union.
An attempt should be made to exchange the existing implant for a nail
that is both larger in diameter (by 1
to 2 mm) and stiffer by increasing the
nail diameter or wall thickness, or
both. The canal should be reamed until osseous chatter is heard; the goal
is to ream 1 to 1.5 mm larger than the
anticipated implant. In axially stable
patterns, consideration should be
given to placing nails in a dynamically locked fashion using the dynamic holes currently available in
most nail designs. Unless significant
atrophic changes are noted on preoperative radiographs, adjuvant open
bone grafting procedures generally are
not performed during the first at-

Journal of the American Academy of Orthopaedic Surgeons

Joseph R. Lynch, MD, et al

Figure 4

Anteroposterior (A) and lateral (B) radiographs of a 52-year-old man with a distal one third femoral diaphyseal nonunion 6
months following treatment with a reamed antegrade statically locked medullary nail. Note the broken distal locking screws.
Anteroposterior (C) and lateral (D) radiographs demonstrating a healed femoral diaphyseal nonunion 6 months following
exchange nailing with a larger-diameter and stiffer implant placed in a dynamic fashion.

tempt at exchange nailing. Open bone

grafting with autogenous graft, however, should be considered when repeat exchange nailing is attempted after failure of one exchange nailing.
Despite union rates that are more
modest than initially reported, exchange nailing for femoral nonunions
allows early weight bearing and unrestricted motion of adjacent joints,
while typically producing higher rates
of fracture consolidation than do less
invasive techniques such as nail dynamization.
Reamed nailing also may be used
as a salvage procedure for nonunion
following plate fixation of the femur.33 Following plate removal, an
appropriately sized locked reamed
nail is placed in the usual fashion.
Consideration should be given to
closing the soft-tissue envelope following plate removal and before
reaming to allow for local deposition
of the reamings.
Volume 16, Number 2, February 2008

Plate Osteosynthesis
Plate osteosynthesis offers specific advantages over nail dynamization and exchange nailing. Plating
offers enhanced mechanical stability
for hypertrophic nonunion. For oligotrophic and atrophic nonunion,
plating may be combined with bone
grafting to enhance both the biologic and the mechanical environment
for union. Although exchange nailing may be considered in oligotrophic and atrophic nonunions,
some of the theoretical advantages
of performing a closed technique are
diminished in patients in whom adjunctive open bone grafting is simultaneously performed to enhance the
local biology. In these situations, the
surgeon should give consideration to
plate osteosynthesis. Open plating
also is indicated in some proximal
and distal metadiaphyseal nonunions
(Figure 5). These injuries can be difficult to manage with medullary nails

because these regions of the femur

will not have direct endosteal contact
with the medullary implant, thus diminishing the stability of the overall
construct. Open reduction and plate
fixation facilitates correction of associated deformity, affords better axial
and torsional stability, and allows for
the application of direct compression
across the nonunion site.34 The treatment of active or indolent infection
associated with femoral nonunion
may be facilitated with plate fixation
by allowing a thorough dbridement
of sequestrum and involucrum via
open techniques.
Bellabarba et al35 reported a 91%
union rate at 3 months in 23 patients
treated with plating for femoral nonunion following medullary nailing.
The authors used the AO 95 condylar blade plate in distal and proximal
one third nonunions of the femoral shaft. They used the broad largefragment dynamic compression plate
93

Femoral Nonunion: Risk Factors and Treatment Options

Figure 5

Anteroposterior (A) and lateral (B) radiographs of a 32-year-old man with a femoral diaphyseal nonunion 10 months following
treatment with a reamed retrograde statically locked medullary nail. Anteroposterior (C) and lateral (D) radiographs
demonstrating a healed femoral diaphyseal nonunion 4 months following nail removal, open dbridement, autogenous bone
grafting, and plate osteosynthesis.

in nonunions of the middle one third

of the femur and emphasized meticulous attention to the protection of
soft tissues. Adjunctive autogenous
bone grafting was used for all atrophic nonunions and selective oligotrophic nonunions that demonstrated a significant bony defect or
unfavorable bony architecture that
would prevent compression without
significant shortening. These authors
considered this technique particularly valuable in the presence of deformity. Abdel-Aa et al36 reported a
100% union rate in their series of
femoral nonunions managed with
plate osteosynthesis. Severely recalcitrant nonunions treated with the
wave plate have been reported to result in union rates between 95% and
98% at 6 to 12 months.9,37 Although
these studies are not directly comparable because of their retrospective
nature, these results are superior to
those reported for exchange nailing.
94

Plate osteosynthesis is not without risks and disadvantages. Compared with closed medullary nailing,
plate osteosynthesis has been shown
to be associated with a higher risk for
infection, greater blood loss, and further devascularization to soft tissues
in an area that has been previously
injured.9,35,37-39 Additionally, plate osteosynthesis frequently requires restricted postoperative weight bearing,
possibly decreasing the benefits of
mechanical loading of the nonunion
site, as well as slowing rehabilitation.
In the study by Abdel-Aa et al,36 13%
of patients required quadricepsplasty
and knee arthrolysis postoperatively
for significant stiffness at 1 year.
Another technique involves the
use of compression plating around the
existing medullary implant. In three
reviews of femoral nonunions managed with this technique, a union rate
of 100% was reported at an average
of 7 months.39-41 This method com-

bines the advantages of medullary

nailing (eg, immediate weight bearing) with the advantages of plate osteosynthesis (eg, the ability to apply
interfragmentary compression) and
offers improved stability in the metadiaphyseal region of a long bone. If desired, autogenous bone grafting may
be performed through the same surgical exposure. We do not have sufficient experience with this technique
to support or refute the evidence presented; however, the advantage of allowing earlier weight bearing combined with the benefits attributed to
compression plate osteosynthesis
make this technique an attractive alternative in the appropriate situation.
Plate osteosynthesis for the management of femoral nonunion following nailing results in a high rate
of union. The authors primary indication for plate osteosynthesis is
metaphyseal and metadiaphyseal
femoral nonunions associated with

Journal of the American Academy of Orthopaedic Surgeons

Joseph R. Lynch, MD, et al

significant malalignment. In situations requiring open dbridement of

infected tissue or in nonunions requiring bone grafting, plate osteosynthesis through the same surgical
exposure is a logical and successful
form of nonunion stabilization. Despite the high reported union rates,
plate osteosynthesis requires large
surgical exposures and may be associated with increased perioperative
morbidity. Important considerations
for successful plate osteosynthesis
include meticulous surgical dissection, limited soft-tissue stripping,
and, when possible, compression of
the nonunion site.
External Fixation
External fixation has been reported for the treatment of femoral
nonunion. The Ilizarov technique
has been described in small case series, with good results in aseptic
nonunions.42,43 The small patient
numbers indicate that these techniques are used less frequently than
dynamization, exchange nailing, and
plate osteosynthesis. Compression
and distraction using half-pin and
tensioned-wire external fixators has
been described as being capable of
providing a mechanical stimulus
that facilitates union.44 However,
pain necessitating strong analgesic
agents and pin-related complications
(eg, osteomyelitis, septic arthritis,
pin failure) continue to be significant
limitations. The complexity and associated economic costs suggest that
these techniques should be limited
to tertiary care centers with experienced surgeons.43 External fixation
may be most useful for managing infected femoral nonunion.
Adjuvant Treatment
Alternatives
Additional treatments have been
used either in isolation or, more
commonly, as adjuvants to one of
the skeletal stabilization methods
previously described. These include
electrical stimulation, bone grafting
and bone graft substitutes, and the
Volume 16, Number 2, February 2008

application of newer biologics such

as BMPs.
The principal advantage of electrical stimulation as an adjuvant treatment is its minimal risk. For this
reason, many surgeons choose to use
it for difficult femoral nonunions in
conjunction with medullary nailing
or plate fixation. Electrical stimulation as a stand-alone procedure for
the ununited tibia has produced
higher rates of healing than casting
alone, but there are few data concerning the femur.45,46 We rarely use
it in isolation. The numerous contraindications to the use of electrical
stimulation include the presence of
a gap at the nonunion site, synovial
pseudarthrosis, and significant osseous devascularization.
Autogenous bone, allograft bone,
bone marrow aspirate, BMPs, and
combinations thereof may be added
to the nonunion site as isolated procedures. The results of aseptic femoral nonunions treated with bone
grafting as an isolated and open procedure have not demonstrated greater efficacy than exchange nailing
alone, and we rarely choose this
technique.47 Most commonly, they
are used as adjuvants along with exchange nailing and plate osteosynthesis techniques. We choose one of
these adjuvants for patients requiring repeat exchange nailing, or when
plate osteosynthesis is used and adequate compression across the fracture site cannot be obtained.
BMP has been studied extensively
in animal models as well as in prospective randomized clinical trials in
humans. It is effective as a treatment
alternative for recalcitrant nonunion
in the tibial diaphysis.10,11 In one
study,11 patients with tibial nonunion were randomized to either recombinant human BMP-7 (rhBMP-7)
or autogenous bone grafting as an adjunct to medullary nailing. Efficacy
of rhBMP-7 was similar to autogenous bone grafting in this study
(81% union with rhBMP-7 versus
85% with graft; P = 0.524). The FDA
issued a humanitarian device exemp-

tion for the application of rhBMP-7

as an alternative to autograft in recalcitrant long bone nonunion in
which the use of autograft is not feasible and alternative treatments have
failed. However, the efficacy of this
adjunctive treatment has not been
specifically reported with femoral
nonunion. Also, the robust bone formation and healing potential demonstrated in animal models has not, as
yet, been as impressive in clinical series evaluating ununited fractures of
long bones in humans.10,11

Summary
Management of acute femoral diaphyseal fracture with a medullary device
has one of the most predictable outcomes in orthopaedic surgery, with
union rates ranging between 90% and
100% in most series. However, when
a femoral shaft fracture fails to unite,
it becomes a difficult problem for the
surgeon and presents significant functional and economic challenges for
the patient. Careful history, physical
examination, and radiographic evaluation can confirm the diagnosis of
nonunion and are essential in formulating an appropriate treatment plan.
Consideration should be given to the
optimization of modifiable risk factors such as nutritional status, nicotine, NSAID use, and medical comorbidities. Treatment options should be
individualized based on patient and
fracture characteristics to achieve osseous union, correct malalignment,
eradicate infection, and optimize
muscle strength and rehabilitation.

References
Evidence-based Medicine: There are
six level I/II studies (references 1, 11,
21, 22, 45, and 46), along with several
level III/IV cohort and case-control
studies (references 2-9, 13-18, 26-28,
30-33, 35-37, 39-44, and 47).
Citation numbers printed in bold
type indicate references published
within the past 5 years.
95

Femoral Nonunion: Risk Factors and Treatment Options

1. Canadian Orthopaedic Trauma Society:
Nonunion following intramedullary
nailing of the femur with and without
reaming: Results of a multicenter randomized clinical trial. J Bone Joint
Surg Am 2003;85:2093-2096.
2. Winquist RA, Hansen ST Jr, Clawson
DK: Closed intramedullary nailing of
femoral fractures: A report of five
hundred and twenty cases. J Bone
Joint Surg Am 1984;66:529-539.
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